Refinement Procedures

Stanford Facial Nerve Center


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Botulinum toxin (Botox™) and Hyaluronic Acid Filler for Facial Paralysis or Synkinesis

Hyaluronic acid (HA) fillers are used for temporary volume augmentation of different areas of the face. Their use in the setting of facial paralysis is not FDA approved and is considered cosmetic.  However, hyaluronic acid fillers can improve some of the symptoms of facial paralysis by improving the symmetry of the cheeks, lips, and other areas of the face.  Likewise, botulinum toxin is helpful in treating unwanted facial movement in synkinesis.  In the Video, a patient of Dr. Pepper’s discusses her experience with botulinum toxin and filler use for facial weakness and synkinesis.

How long do these treatments last?

In general, botulinum toxin treatments last for three months.  Filler lasts between six months to two years, depending on the type, amount, and location of the filler injection.

Brow lift for facial paralysis or synkinesis

Facial paralysis can result in drooping of the eyebrow. This can be severe enough in some cases to cause obstruction of vision in that eye.  To treat this visual obstruction and improve the symmetry of the eyebrows, a brow lift can be performed. The most common means of lifting the brow in facial paralysis are either a direct brow lift, where skin is removed just above the eyebrow, or an endoscopic brow lift, where the brow is elevated using an endoscope. Small incisions placed in the hair-bearing scalp.  An endoscopic browlift is particularly helpful for the treatment of synkinesis, if the abnormal facial movement affects the eyebrow region. A patient who had a facelift performed by Dr. Pepper is shown in Figure 1 and Figure 2. Brow lifts take about 1.5 – 2 hours to complete and usually require general anesthesia, depending on the technique chosen. For recovery, we recommend two weeks off of work.  Expect that swelling and any bruising will resolve in 2 or 3 weeks.

A patient of Dr. Pepper’s, before and after endoscopic brow lift performed for left eyebrow synkinesis.  Her face is relaxed. Note the symmetric brow position in the after photo, seen at right.

Before and after endoscopic brow lift performed for left eyebrow synkinesis, with eyes closed. Note the softer muscle contractions in between the brows in the image on the right.

Facelift for facial paralysis

Some patients with facial weakness may benefit from a facelift (rhytidectomy) on the side of their facial paralysis. The goal of this facelift, as in all facelifts, is the elevation of redundant and drooping soft tissue near the jawline and neckline.

This is not a facial reanimation surgery, but can improve resting symmetry and have a pleasing effect on the appearance of the face. 

Facelifts take about 4 hours to complete, require general anesthesia, and are usually performed as an outpatient.

For recovery, we recommend two weeks off of work. Expect that swelling and any bruising will resolve in 2 or 3 weeks.

Incisions for a routine facelift after the procedure is complete. Skin incisions are shown in red. Stitches under the skin the hold the lift are shown in gray.

Depressor Anguli Oris (DAO) Myectomy

The depressor anguli oris (DAO) muscle is a facial muscle that originates from the mandible (jawbone) and inserts near the corner of the mouth. When activated the DAO muscle causes the lips to move downward, like a frown. In some patients with synkinesis after facial nerve injury, this muscle activates when they attempt to smile.

This causes the corner of the mouth to drop downward, instead of move upward, when they try to smile. Lidocaine can be injected into this muscle in clinic to simulate the targeted removal of a portion of the DAO muscle, a procedure called a DAO Myectomy. When lidocaine is injected into the muscle, it causes temporary paralysis of the DAO muscle. If this is associated with improved smile, then patients may consider DAO Myectomy in order to improve their smile.

Please see the video for further explanation about how a lidocaine injection to the DAO muscle can be used to determine whether a DAO Myectomy procedure is helpful in the treatment of synkinesis.